Women’s health in MS – contraception and the transition through menopause

Overview

Women living with multiple sclerosis (MS) often face unique challenges related to reproductive health, often around contraception and the transition through menopause. This 60-minute webinar will explore how MS and it's symptoms can crossover with key stages of women’s health, and how healthcare professionals can best support patients through informed, personalised care.

Led by clinicians from neurology and primary care with a specialist interest in women's health, the session will provide evidence-based guidance and real-world insights to improve clinical practice across a range of care settings.

Aims and objectives

This session will help healthcare professionals to:

• Understand how MS and disease-modifying therapies (DMTs) may influence contraceptive choices.
  
  

• Identify and differentiate between menopause-related symptoms and MS symptoms.
  
  

• Explore the role and safety of hormone replacement therapy (HRT) in women with MS.
  
  

• Apply case-based insights to deliver person-centred care through key stages of reproductive life.
  
  

• Collaborate effectively within multidisciplinary teams to support women’s health in MS.

Summary

MS predominantly affects women, making understanding how it interacts with hormonal changes, contraception, and menopause of the utmost importance.

In this webinar, Dr Kate Petheram, consultant neurologist at South Tyneside and Sunderland NHS Foundation Trust, Ruth Stross, head of nursing at the Neurology Academy, and Dr Nichola Osborne, general practitioner with a specialist interest in MS and women’s health, focused on the intersection of MS and menopause and the need for personalised care.

“We recognize that menopause is generally dealt with in primary care,” said Kate, “but it is important for us to be as informed as we can, so we can pass that information on to our primary care colleagues.”

Why women’s health matters in MS

MS disproportionately affects women, and is typically diagnosed before the age of 50. It means that many will navigate the complex hormonal transitions of menstruation, contraception, and menopause while also managing a chronic neurological condition.

Despite this, women's health in MS remains an underexplored and often misunderstood area.

The Women’s Health Strategy for England, published in 2002 recognised that women live longer than men but tend to spend more time in poor health. Menopause was identified as a key area of focus, and neurologists were specifically highlighted as healthcare professionals who should have a basic understanding of menopause and women's health issues.

“Women's health is a real opportunity for personalised medicine,” said Kate. “Female hormones do not stay static throughout a woman's life. Rather than ignoring these changes, we need to acknowledge them and realise that a person with MS potentially needs to be managed slightly differently through these different stages of life.”

Contraception and MS

Giving a brief overview of contraception , Kate said that all methods are safe in MS. There is no evidence, she went on, to suggest that oral contraception is associated with increased relapse rates.

Decisions should be taken based on individual risk factors. It is worth noting, for example, that Depo-provera can potentially affect bone density, especially around hormonal changes. Healthcare professionals should also consider the risk of blood clots with combined oral contraceptives in those with prolonged immobility.

What is menopause?

Nicola explained that menopause is a life event that can be very different for each woman.

Perimenopause, defined as the months or years leading up to menopause, is characterised by irregular periods and, in some, the onset of menopausal symptoms. It typically starts in mid to late 40s. Menopause itself is diagnosed when it has been one year since a woman's last period, where as post-menopause is the time after menopause.

“Menopause can range from being barely noticeable for some women to being a time of significant physical and emotional changes for others,” said Nicola. “It involves fluctuations and a gradual reduction in estrogen and progesterone levels, which can impact various aspects of a woman's health and well-being.”

Menopause is also associated with a range of potential health risks, including osteoporosis, cardiovascular issues, diabetes, and osteoarthritis. Key recommendations from the speakers was to focus on individualised lifestyle modification, whether that be smoking cessation, reducing alcohol consumption, exercising, or improving nutrition.

It is, they all agreed is as a chance to review, and potentially improve, overall health and lifestyle choices.

Menopause is primarily a clinical, rather than a laboratory-based, diagnosis. Using a single blood test, such as follicle-stimulating hormone (FSH), is not helpful as hormone levels fluctuate depending on the stage of the woman’s cycle.

“It is really difficult to know what stage somebody is at, particularly in the younger group of women who are taking contraception,” said Nicola. This is compounded by overlap in symptoms.

Untangling MS symptoms from those related to menopause can be challenging, said Ruth.

“Some are clearly linked to menopause, while others have a clearer link to MS, but there is a crossover,” she said, explaining that the most common “crossover symptoms” were fatigue and sleep disturbance, mood, cognition, and mental health issues, and urinary and sexual health issues.

Encouraging people to track cycles and diarise symptoms, Nicola added, can be a helpful way “to get an idea of what their cycles look like and whether they are changing”.

Ruth emphasised the importance of taking a full history when discussing such symptoms. ”I know we are really time poor at the moment, but where possible, we need to try to get as much information as we can, looking at timings and patterns. It is only by really listening closely to the women's experience that we can get a better understanding of what is going on and make the best referrals.”

HRT

Hormone replacement therapy (HRT) aims to replace estrogen and protect the endometrium with progesterone. This can help control menopause symptoms like brain fog, hot flushes, mood changes, and sleep disturbances. It can also protect against cardiovascular disease, particularly in those aged under 60, and reductions in bone density.

Nicola explained that estrogen-only HRT is associated with little or no increased risk of breast cancer. Combined HRT, i.e. estrogen and progesterone, can be associated with a small increased risk of breast cancer in some. This is related to the duration of treatment, and the risk may reduced after HRT discontinuation.

Different types of HRT and different routes of administration have different side effect profiles. As such, there is “no one size fits all” and personalised medicine is key. Healthcare professionals should consider the person’s individual risk factors when making decisions

Towards a better understanding

Ruth went on to discuss the MS and Menopause Stakeholder Group, which includes representation from the NHS England menopause lead and the NHS England menopause stakeholder group. The aim is to provide education for healthcare professionals and women with MS.

So far, the group has developed a menopause and MS education clinic, and conducted focus groups with healthcare professionals and patient groups

One memorable piece of feedback from the patient focus group, Ruth said was "the last thing you want to do is lose more brain to menopause", highlighting the personal impact of these symptoms.

The group is currently preparing to trial the educational clinic in a few selected centres.